Mountains Beyond Mountains
Chapter 21
Summary & Analysis

LitCharts assigns a color and icon to each theme in Mountains Beyond Mountains, which you can use to track the themes throughout the work.

Cost-Efficiency vs. the Value of Life

Saintliness

America, Imperialism, and the First World

Science, Magic, and Religion

Nonprofits, Politics, and Compromise

Summary

Analysis

Kidder and Farmer land in Havana, and Farmer ecstatically notes the beautiful trees and green fields. Although Cuba is only 90 miles away from Haiti, its environment is far healthier. Farmer has great respect for Cuba—not as a communist society, but as an exemplar of good health. Cuba has largely gained control of the diseases that ravage Haiti: typhoid, TB, and AIDS. The story of Cuba’s public health programs, Farmer insists, is a miracle: despite its lack of funding from the U.S., its rocky relationship with the Soviet Union, and its long history of poverty, Cuba has become a model for third world countries. Cuba has even sent a team of 500 doctors to Haiti, where they work for free.

From the perspective of the United States, Cuba is a danger: a Communist dictatorship, located only a few hundred miles away from the U.S. And yet it’s hard not to be impressed with the state of Cuba’s healthcare. Similarly, it’s hard not to think that Cuba’s medical superiority is related to its success in remaining free of American military and economic control. Haiti may be a democracy (and therefore closer to the U.S.), but it’s deeply poverty-stricken, and part of that comes from its history with the West: a history of slavery, imperialism, and military interference.

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Farmer has a conflicted relationship with communism. He finds it perfectly obvious that society is locked in a class struggle—one of the fundamental tenets of Marxism. He also respects communist ideology for embracing liberation theology. Yet Farmer also finds communist culture to be arrogant, and overly orthodox—one of the reasons that science never flourished in the Soviet Union. In general, Farmer distrusts “-ologies” altogether. His goal, he says, is to be as open-minded as possible.

Farmer’s views on Communism are predictably balanced. He sympathizes with many Communist tenets—particularly the idea that classes compete with one another for power. But because Farmer is first and foremost a doctor, he has a hard time accepting all of Communism. As with Catholicism, he accepts and doubts it at the same time, and avoids any belief system that is too rigid or stands in the way of universal compassion.

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Farmer has flown to Cuba to attend a medical conference, visit a friend, Dr. Pérez, and buy antiretroviral AIDS drugs. He also wants to look into Cuba’s new medical school—an institution that, he hopes, could be used to train Haitian doctors. At the medical school, Dr. Pérez arranges for Farmer to meet with the president of the school, Dr. José Miyar Barruecos. Farmer asks Barruecos if he’d accept two Haitian students, and Barruecos agrees.

Farmer doesn’t want to create a “cycle of dependency” in Haiti, whereby he continues giving the Haitians free healthcare and they grow dependent on outside help. Rather, he wants the Haitians to learn to take care of themselves, and enrolling Haitian students at Cuba’s medical school is an important step in this direction.

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At the medical conference, Farmer meets Luc Montagnier, the doctor usually credited with discovering AIDS. Farmer and Montagnier discuss the idea of establishing a “triangle” between Cuba, France, and Haiti, so that the three countries can exchange doctors, research, and funding. Farmer also delivers a talk on the history of poverty in Haiti, and its relationship with the AIDS epidemic. He argues that classifying Haitians as an “at-risk” AIDS group indicates U.S. racism and prejudice. Haitians aren’t especially promiscuous, and barely any of them use drugs; in other words, Haitians aren’t particularly at-risk for AIDS. Farmer argues that developed nations like the U.S. focus too exclusively on white victims of the AIDS crisis, ignoring the Haitians whenever possible.

It’s hard to argue that the U.S. interprets the AIDS crisis—and most health crises—in racial terms. Thus Haiti is considered to be an “at-risk” place, not because of medical facts about AIDS, but because Haiti is seen as inferior, foreign, and dangerous. Despite all empirical evidence to the contrary, the U.S blames Haiti for its own problems: a clear sign of America’s condescension and disdain for its island neighbor.

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After the conference, Farmer gets to work on his latest book, which is about the history of inequality and imperialism as reflected in national health policy. He tells Kidder that many of the measures being used to fight AIDS in North America—such as “AIDS sanatoriums”—resemble concentration camps.

Many have argued that the response to the AIDS crisis in the U.S. devolved into an excuse to persecute gays, blacks, and other minorities. Thus, gay people were feared and stigmatized for being HIV carriers, and yet they also weren’t given the healthcare they needed—much like the Haitians, they were blamed for their problems, but no efforts were made to care for them.

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The next day, Farmer and Kidder go on a tour of a Cuban sanatorium designed for AIDs patients. Farmer notes that there’s almost no medical evidence that quarantines have any great effect on the AIDs epidemic. To Kidder’s great surprise, Farmer praises the Cuban sanatorium quarters, calling them “pretty nice.” Kidder finds it difficult to sort through his own feelings on quarantine practices. Cuba, he notes, has one of the lowest rates of AIDS infection in the Western world. In part, this could be because the Cuban government acted quickly to isolate the infected, and reduced trade and travel with Africa and the U.S.

This is one of the most ambiguous passages in the book: it’s hard to tell what Farmer really believes about Cuba. While it’s true that Cuba has reduced the cases of AIDS, it’s also true that it has done so by drastically limiting people’s freedoms: sending some to quarantine and reducing trade with other countries. (It’s reminiscent of the old saying that dictators “make the trains run on time.”) There seems to be an inescapable tradeoff between personal freedom and health—a harsh reminder that in the real world, healthcare involves making some difficult decisions.

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Kidder notes that Farmer travels more than anyone he’s ever met, and yet he’s never seen the tourist destinations in the countries he’s visited: he’s been to Peru, but not Machu Picchu, for instance. Farmer’s traveling, he claims, is a part of his medical practice—he needs to inspect facilities around the world to make sure that Zanmi Lasante is up to par. He tells Kidder that his visit to Cuba has inspired him to improve conditions in his hospital in Haiti.

Farmer travels, but he’s no tourist—he’s in Peru, Haiti, etc., to help the poor, not to enjoy himself. Indeed, he seems to “enjoy himself” by helping the poor, as he apparently feels no need or desire to take any kind of vacation from his work.

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As they’re preparing to leave Cuba, Kidder suggests to Farmer that the Cubans must love Farmer for his denunciations of U.S. foreign policy, as he plays into their communist agenda. Farmer seems offended by this, and Kidder feels guilty for offending him. Later, on the flight, Farmer tells Kidder that journalists who write about passionate people usually “give the reader a way out”: they portray the person’s passion as a kind of obsession or psychosis, or suggest that the person has a political or ideological agenda. Farmer adds that he has no personal stake in the way Kidder depicts him, but his patients will suffer if Kidder paints Farmer as a political pawn. Farmer never mentions the matter again.

Farmer is deeply conscious of the fact that Tracy Kidder, a famous, Pulitzer Prize-winning author, is writing a book about him: i.e., he knows that Tracy’s impressions of him will color the way he’s perceived around the world. As a result, one could argue, Farmer uses the most important weapon he has: the fact that he’s a doctor for thousands of people. By reminding Kidder of this undeniable fact, he’s warning Kidder to present him in a favorable light. At the same time, we’ve seen ample evidence that Farmer is not, in fact, a political person: his priority is helping patients, not pushing dogma.

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Farmer and Kidder’s next trip is to Russia, by way of Miami and Paris. Kidder considers the small argument he and Farmer have just had. In the past, Kidder has wondered if Farmer’s devotion to the poor is a kind of alibi: a way of defending himself from any and all attacks or criticisms. Farmer has devoted his entire life to helping people in need—thus, any attack on him could realistically be interpreted as an attack on his patients. But as Kidder sits next to Farmer on the plane, it’s apparent to him that Farmer isn’t posing in any way: he considers it his duty—in a way his only duty—to help those in need.

Kidder acknowledges that Farmer has an unbeatable defense whenever anyone disagrees with him: he can say that his opponent is threatening the health of thousands of people. At the same time, Kidder seems to acknowledge that this kind of thinking is petty and foolish: a confirmation of his own “inferior” moral status, rather than Farmer’s. There’s no real way to prove that Farmer is wholly sincere and consistent in his drive to help others, so we just have to take the word of his friends and acquaintances—people who have spent enough time with him that they would presumably be able to notice any insincerity or ulterior motive behind his actions.